Texas Department of Public Safety • MUST USE MOST CURRENT FORM PRIVATE SECURITY

Regulatory Services Division • PRINT CLEARLY IN BLACK INK EXAMPLE: www.dps.texas.gov • MAKE SURE ENTIRE CIRCLE IS FILLED Yes No

PRIVATE SECURITY INFORMATION CHANGE FORM - BUSINESS GENERAL INFORMATION I understand that this form is ONLY to be used to change address, phone numbers or e-mail addresses. This does NOT include company name change.

Yes

No

Type of Change: Company Branch THE ABOVE SPACE IS RESERVED FOF OFFICE USE ONLY

ONLY FILL OUT THE APPROPRIATE SECTION

PART I . COMPANY ONLY Company Name

Company License No.

NEW Mailing Address

City State (2- Letter Code)

ZIP

NEW Physical Address

City State (2- Letter Code)

ZIP

NEW Business Phone

New Business Website

NEW Business Email

Last Name Of Contact Person (IF DIFFERENT THAN SIGNER) First

Name Contact Person’s Phone

Contact Person Email

Manager Printed Last Name Printed

First Name

Manager Email

PART I I . BRANCH ONLY Company Name

Branch License No.

NEW Physical Address

City State (2- Letter Code)

ZIP

NEW Branch Phone Last Name Of Contact Person (IF DIFFERENT THAN SIGNER) First

Name Contact Person’s Phone

Contact Person Email

Manager Printed Last Name Printed

First Name

Manager Email

SIGNER INFORMATION Printed Last Name Of Person Signing (IF DIFFERENT FROM MANAGER LISTED ABOVE) Printed

First Name

I verify that the information provided is true and correct, and I understand that this is an official government record and that any false statement made on this document or any other supplement provided to the Department may result in criminal prosecution.

Printed Name of Manager, Manager’s Designee or Owner _______________________________________ Date____________

Manager, Manager’s Designee or Owner Signature _______________________________________ Date____________

This form and any attachments may be forwarded electronically to:

https://www.dps.texas.gov/rsd/contact/psb.aspx PSP-16A (Rev. 03/2017) Page 1 of 2 FORM

Note: It is not required to submit Page 2 of this form. Privacy Policy Sec. 559.003. RIGHT TO NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES (a) Each state governmental body that collects information about an individual by means of a form that the individual completes and files with the governmental body in a paper format or in an electronic format on an Internet site shall prominently state, on the paper form and prominently post on the Internet site in connection with the electronic form, that: (1) with few exceptions, the individual is entitled on request to be informed about the information that the state governmental body collects about the individual; (2) under Sections 552.021 and 552.023 of the Government Code, the individual is entitled to receive and review the information; and (3) under Section 559.004 of the Government Code, the individual is entitled to have the state governmental body correct information about the individual that is incorrect. (b) Each state governmental body that collects information about an individual by means of an Internet site or that collects information about the computer network location or identity of a user of the Internet site shall prominently post on the Internet site what information is being collected through the site about the individual or about the computer network location or identity of a user of the site, including what information is being collected by means that are not obvious. Please visit: http://www.statutes.legis.state.tx.us/docs/GV/htm/GV.559.htm

PSP-16A (Rev. 03/2017) Page 2 of 2 FORM